Kaiser Permanente

Exclusions and Limitations

As with all health plans, there are some exclusions. The following services are excluded from all coverage. (Please note that this is a summary - for a complete list, refer to the Personal Advantage Evidence of Coverage.)

Services which an employer or any government agency is responsible to provide, include workers' compensation Custodial care or care in an inter-mediate facility Services provided or arranged by criminal justice institutions or mental health institutions for Members in custody of law enforcement officers if you are confined in the institution, except for emergency services Cosmetic Services (including drugs and injectables) Cord blood procurement and storage for possible future need or for a yet-to-be determined member recipient Dental Services orther than those specified (including most hospital services for dental use) Physical examinations required for obtaining or maintaining employment or participation in employee programs, or insurance or government licensing Experimental or investingational services Refractive surgery or corrective lenses, eyeglasses, and hearing aids Orthoptics (eye exercises) Services and drugs related to the treatment of obesity Routine foot care services Examinations for the prescription of hearing aids Cost of semen and eggs

Services for conception by artificial means including infertility drugs Reversal of voluntary infertility Nonhuman and artificial organs and their implantation Court-ordered services Mental health services for chronic conditions and mental retardation after diagnosis Testing for ability, aptitude, intelligence, or interest Corrective shoes and orthotic foot supports and inserts More than one device for the same part of the body or same function Replacement of lost devices Dental devices and appliances other than those specified Electronic monitors of bodily functions (except infant apnea monitors and blood glucose monitors) Devices to perform medical testing of body fluids, excretions, or substances Devices not medical in nature Convenience, comfort, or luxury items Disposable supplies for home use Reconstructive surgery following the removal of breast implants that were inserted for cosmetic reasons Drugs for the treatment of sexual dysfunction disorders Most disposable supplies Transportation and lodging All services and drugs related to sexual reassignment surgery Long-term physical, speech, and occupational therapy and rehability Cognitive rehabilitation programs Vocational rehabilitation Services that are primarily educational in nature

This is a summary description and is not intended to replace your Individual Agreement or Personal Advantage Evidence of Coverage, which contain the complete provisions of this coverage. If you have questions or need additional information, please call (404) 575.1960.